Lichen sclerosus is a chronic skin disorder that most commonly affects post-menopausal women. However, it is sometimes identified among pre-menopausal women, and, even more rarely, among males. When found in males, the disease is known as balanitis xerotica obliterans.
Lichen sclerosus is characterized by skin changes of the external genitalia (i.e., vulva, head of the penis), although other parts of the body may also be affected. Intense itching often accompanies attacks of lichen sclerosus. The disorder is not contagious nor is it a sexually transmitted disease. In the recent past, a genetic component for lichen sclerosus has been recognized. In addition, many clinical researchers believe that it is a disorder of the immunological system. The understanding of the causes of this disorder is still incomplete. Lichen sclerosus can develop concurrently with other conditions.
Lichen sclerosus usually affects the external genitalia (i.e. vulva, vagina, or penis) and/or the area around the anus (perianal region). Sometimes, it is accompanied by intense (intractable) itching. If the disease is severe, even minor abrasions or chaffing can cause bleeding, tearing, and blistering. For this reason, many affected women and men avoid sexual activity, tight undergarments, and such activities as riding bicycles.
For children with lichen sclerosus affecting the perianal region, constipation may be among the first signs of the presence of the disease. Lichen sclerosus is much more likely to affect males that have not been circumcised than males that have been.
Skin tissue often becomes thin, shiny, wrinkled and parchment-like. Fissures, cracks, and purplish patches (ecchymoses) appear frequently. An eruption of bluish-white pimples, either separate or joined together, containing a central depression or a black plug of hard skin occurs. Swelling of the skin, overgrowth of skin (epidermal hyperkeratosis), loss of skin tissue, (atrophy), and inflammation are accompanied by soreness and itching. Shrinkage of the skin of the vagina and vulva, often accompanied by a chronic inflammation in the deeper tissues (kraurosis vulvae), may also occur.
In males, lichen sclerosus most commonly affects the foreskin of the penis, although it may affect other areas of the body. The opening at the end of the foreskin may become narrow and scarred. Discoloration and skin changes may also occur. Symptoms also include itching, soreness, and painful erections.
Thick, white patches of skin (leukoplakia) that are slightly raised may develop on the penis or vulva.
In some rare cases, skin lesions may also develop in the mouth. The lesions consist of bluish-white flat patchy areas on the inside of the cheeks and/or palate. The tongue may also be involved.
The exact cause of lichen sclerosus is not known. It may be due to an autoimmune process, or an injury, or may follow radiation therapy. Autoimmune disorders arise when the body’s natural defenses against “foreign” or invading organisms (e.g., antibodies) begin to attack healthy tissue for unknown reasons. Some cases of lichen sclerosus may be linked to formation of certain antibodies (e.g. a thyroid protein (thyroglobulin), or certain cells that line the walls of organs.
Some scientists believe that a genetic predisposition to lichen sclerosus exists. A genetic predisposition means that a person may carry a gene for a disease but it may not be expressed unless something in the environment triggers the disease.
Lichen sclerosus affects mostly females, usually between the ages of 40 and 60 years. Cases involving younger females and males have also been identified in the medical literature in the United States, and cases have been reported that involve female children under the age of thirteen. Females are six times as likely to be affected as are males.
Lichen sclerosus is diagnosed in advanced cases by looking at the skin affected. Milder cases require a thorough clinical evaluation, identification of characteristic physical features, and a detailed patient history. In order to be sure of the diagnosis in mild cases, a skin biopsy is almost invariably undertaken.
Patients with non-genital lichen sclerosus should remain watchful about the course of the disease but may not need to treat it. However, even mild symptoms of genital or perianal lichen sclerosus should be treated in order to avoid the scarring that can lead to the narrowing of vaginal or anal openings.
Treatment consists of the use of one or another of the ultrapotent corticosteroids that are available by prescription as a cream or ointment. Ultrapotent corticosteroids available in the United States include: betamethasone diproprionate, clobetasol propionate, diflorasone diacetate, and halobetasol propionate. These drugs may stop the itching within days or a couple of weeks. Within a few months of regular use, they may make it possible for skin to regain its strength and texture, but they cannot affect scarring or changes in skin color that may already have taken place.
In very severe cases, surgical removal of affected skin layers may be of benefit. In males, circumcision may be helpful (if the foreskin is involved).
Clinical trials of low-dose ultraviolet light therapy, either alone or in combination with drug therapy, have been reported. More studies are needed to determine the efficacy and safety of this treatment for patients with lichen sclerosus, as well as the potential duration of relief from symptoms.
Information on current clinical trials is posted on the Internet at www.clinicaltrials.gov. All studies receiving U.S. government funding, and some supported by private industry, are posted on this government web site.
For information about clinical trials being conducted at the NIH Clinical Center in Bethesda, MD, contact the NIH Patient Recruitment Office:
Tollfree: (800) 411-1222
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FROM THE INTERNET
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